ACR Presidential Address: Rheumatologists—Folks You Can Trust
Authors: Kenneth G. Saag
Journal: Arthritis & Rheumatology (2023)

Saying it is good to be back is a significant understatement about how we all feel to be here in Philadelphia, a city rich in rheumatology history. After 3 years of pandemic-associated challenges, we now have a chance to network with over 7,000 of our colleagues and friends, here at the largest in-person rheumatology meeting since the start of the pandemic. This is just what the doctors have ordered. As your 85th President, it is also my great honor and distinct pleasure to welcome several thousand of you joining us virtually, to our first ever hybrid annual meeting. We hope everyone will be energized by the great science, and for those here in person, the networking and a chance to enjoy Philadelphia. This year, I was very fortunate to work with an outstanding and multi-talented executive committee and exceptional Board of Directors. I want to thank you all for your great many hours of planned and unplanned incredible work this past year. These great groups were complemented by one of the most competent and dedicated professional staffs of any organization in the country, led by our Executive Vice President, Mr. Steven Echard. I am indebted to you all for your time and substantial expertise. As another highlight this past year, we got back to Capitol Hill twice to carry out our most important advocacy activities (Figure 1). I also was very fortunate this year, for the first time in several, to be able to meet in person with trusted and cherished international colleagues. Rheumatology does not start and stop at borders, and our global engagement remains a key priority for the College. While many of us are beginning to feel a greater sense of normalcy, we are all too well aware that things about our field have changed, and we are living in a still challenging time, albeit one with many great opportunities. Our relationship with our patients and the ACR is based on one thing above all else: Trust. Trust is defined as assured reliance on the character, ability, strength, or truth of someone or something. Now, more than ever before, we must embrace these descriptors. Trust, in general, is under great assault and is increasingly being challenged by skepticism and misinformation. I hope to bring you a message of how our unique role as rheumatology health professionals—and I will use that more inclusive term to refer to both rheumatologists and other clinicians caring for our patients with rheumatic diseases—positions us to be leaders in maintaining and re-establishing trust with our patients and with society at large. I will discuss 4 areas of challenges and resultant opportunities that we face. These topics range from our continued response to COVID to general threats to modern medicine today that clearly impact rheumatology. The ACR tackled COVID head-on, and I am indebted to my predecessors, Drs. Ellen Gravallese and David Karp, as well as the many committee members, particularly our outgoing Quality of Care Committee Chair Dr. Sindhu Johnson, and ACR staff, especially Ms. Amy Turner, for their steady hands in steering us through rough waters. Through these gallant efforts to cull evidence and provide guidance, we became a trusted national resource at a critical time in history. Although the imminent threat of COVID has at least transiently abated, somewhat, for many of us, COVID continues to be a major disrupter and a persisting significant concern, particularly for many of our immunocompromised patients. In its wake, many rheumatology health professionals have seen altered revenues, a partial switch to telehealth, and staffing issues due to sickness and quarantine. COVID has complicated the current culture of work and has heightened questions around work–life balance. We now see nonclinical work as less constrained by time and space (1) (Figure 2). Many of our administrative and research staff and faculty, particularly in our academic, industry, and government centers, view at least partially remote work as a key job benefit. While this no doubt improves work–life balance for some, it has also led to a stifling of the “water cooler discussion,” which has challenged our ability to innovate. The “great resignation” has fueled the need for hiring of quality new staff who have been very tough to find to help manage our research and academic centers. Perhaps the most major residual theme of COVID is mistrust and uncertainty. New offerings by the ACR to embrace these challenges were plentiful. Under the expert leadership of Drs. Evelyn Hsieh and Swamy Venturapali, we rolled out a new ACR Strategic Plan. Resulting from a task force led by Drs. Angus Worthing and Abbey Abelson, we started operating under a new Governance structure that led to Board of Directors meetings with more intimate discussions. We have established new membership models, allowing small teams of health care providers to join the ACR en bloc. We will continue to offer virtual meetings to complement our live meeting offerings. Through our Registry and Health Information Technology Committee, expertly led by Dr. Will Harvey, we also are growing wonderful existing ACR resources, such as the RISE registry, the largest rheumatology Electronic Health Record registry, now containing nearly 3 million patients and over 30 million visits overall. It is estimated that 50% of current US rheumatologists will retire in the next 10 years, leading to a 25% reduction of our work force (2). This constitutes an existential threat to our care for an increasing number of patients, resulting, in part, from a global “silver tsunami.” We have a significant maldistribution of rheumatologists that continues to grow. Burnout is rampant. We have far too few rheumatology fellows and postdocs going into research. Our workforce has low diversity. Let me go into each of these in a bit more detail and explain how the ACR is addressing them. An outstanding joint ACR and Rheumatology Research Foundation committee, led by Dr. Dan Battafarano and Ms. Connie Herndon, has creative solutions to grow and sustain not only the rheumatology workforce, particularly in underserved regions, but a workforce of Arthritis Health Professionals, and, partnering with regional stakeholders, other types of health care providers who might receive more limited training in less complex rheumatologic diseases. While we are sadly turning away nearly 100 fellowship applicants annually, we cannot simply add enough slots fast enough to train ourselves out of this crisis. We need new ways to grow and sustain musculoskeletal disease providers. This is a nefarious problem that predated COVID, but which COVID has no doubt exacerbated. We all know of outstanding rheumatologists, well under a typical retirement age, who have elected to leave rheumatology in the recent past. Treating the electronic health record, instead of having time to manage our patients’ concerns, and dealing with the increasingly time- and cost-intensive administrative burden of care delivery, has added hours of uncompensated labor, led to loss of autonomy, and diminished job satisfaction. While the ACR Workforce Solutions Committee will tackle some of this, the ACR must also help foster creative solutions to practice and electronic health record redesign, continue to lobby for reimbursement of the full musculoskeletal care team, and push to get very badly needed payment reform. We understand the need to work fast to maintain the trust of our colleagues, and to continue to position the ACR as the leader in clinical care support—this at a time of unprecedented work–life stress and the need for better professional fulfillment. Despite intense interest in rheumatology as a specialty, we are not matriculating as many applicants who have interest in investigative careers. The numbers were poor in the 1980s and they have become even more dismal (3-7) (Figure 3). This comes at a precarious time as we move towards more personalized and evidence-based care. There are many possible reasons for this loss of interest in research careers and these include: limited interactions of trainees with scientists; demoralized scientists due to lost funding; debt limiting career choices; and COVID. We must continue to create and sustain new funding pathways, particularly for early career scientists, such as our successful national advocacy for loan repayment. We also must continue working with our leaders at the NIH and other funding agencies to make a compelling case for funding mechanisms that sustain investigators of all types at a difficult time in funding. Simply put, we need more funding, but in particular, we must support those doing team science and translation research of greatest public health relevance. We must invest in research infrastructure, innovative training, possibly in collaboration with other groups such as EULAR, and in diversity activities aimed at our research workforce. A truly critical challenge is that we must broaden our research community, our membership, and our ACR leadership to better reflect society as a whole. As Marian Wright Edelman said, “You cannot be what you cannot see” (8), which highlights the need for more representation and speaks to the need for more diverse membership, and, in particular, leadership within all facets of medicine, rheumatology, and the ACR. We started my President year with a highly interactive leadership development activity focused on diversity, equity, inclusion, and accessibility (DEIA), and we end this year with a reception here at Convergence of medical students who are underrepresented in biomedical science. This event is sponsored by our new DEIA Subcommittee led by Drs. Ashira Blazer and Irene Blanco, and under the aegis of our new ACR Diversity Director, Michele Andwele. While this is only a start, a key ACR focus must be enhancing the pipeline of medical students, residents, and fellows historically underrepresented in medicine. We need to be a more representative specialty to enhance trust. DEIA is a cross-cutting theme of our new strategic plan. Medical mistrust and misinformation has become rampant in the COVID era. Social media has fueled it (9), and its toxic flames are regrettably burning bright. Misinformation has eroded trust for academic medicine, private sector biomedical research, and evidence-based thinking overall. There has been a severe diminution of the trusted voice, leading to even physical threats to those who provide invaluable public health information. David Leonhardt, in a New York Times opinion piece titled “Follow the Science” (10), emphasizes that we must do a better job of explaining medicine to society. We must build trust by always following the best available evidence, but must also explain that evidence changes over time, and it does so rapidly, particularly in new and fast-moving events like COVID. We can help because we have long-standing trusting relationships with our patients, and we are well poised to help promote evidence-based thinking. As Adam Grant writes in his book Think Again, rheumatologists achieve trust by being scientists, not preachers, not politicians, not prosecutors (11) (Figure 4). We are constantly rethinking things and we are used to uncertainty. This is in contrast to some of our proceduralist colleagues, who must be more immediate in some of their decision-making, but sometimes lapse into a certainty less well supported by evidence. Rheumatologists are among the least dogmatic of all physicians. As master clinician Ron Anderson puts it, “Part of the differential diagnosis is that you are wrong” (12). While there are clearly times when we may be wrong, or at least uncertain, we also recognize that some things, such as a COVID vaccination reducing mortality, are based on the highest level of evidence, and they are undisputed facts. Various groups, such as the American Board of Internal Medicine (ABIM), with our subspecialty Rheumatology Board led by Dr. Dino Kazi, are now identifying those with medicine certification who are espousing the most clearly inaccurate information (13). California already has taken a proactive approach to flagrant misinformation (14). Thankfully, we currently know of no rheumatologists who fit this bill, but we should support efforts to identify and eliminate the most damaging misinformation, and call it what it is, as others scientists have, including Carl Bergstrom (15), the keynote speaker at this year's American College of Epidemiology meeting. At the same time we applaud these efforts, we also recognize that where we have true uncertainty, freedom of speech and honest exchange of contentious ideas is a positive discourse. This then brings me to the final issue of, how do we conduct our business at the ACR around many circulating geopolitical questions that increasingly cross our path? How do we balance what is good for our membership with what is good for our society overall? We have had many recent things to consider as geopolitical controversies this year and in the recent past, including voting rights, climate change, the Ukraine war, and Roe vs. Wade. Our response to the Supreme Court of the US Ruling on Dobbs v Jackson was deliberate, comprehensive, and timely. A particular subissue that arose from this highly contentious judicial ruling was the potential of restricted access to drugs, drugs such as methotrexate, drugs that some of our patients of childbearing potential have been using for years (16). As of the 2022 Convergence meeting, the repercussions of this potential problem, thankfully so far, has not been widespread, but time will tell. Our ACR Board of Directors and Special Task Forces spent many hours addressing this critical matter, and we did many things to promote our Board positions widely in the scientific and lay media. I want to thank all the great volunteers and staff for these tremendous efforts. Why should we get involved in such issues? First, because we are a trusted source of information and we care, we follow the Hippocratic Oath and we care for even those with whom we may disagree. Our voices count. When we are unclear on the role of the ACR in these issues, we must do what we collectively view as the “right thing,” at least as best as we can determine it. Doing what is right is not always straightforward, but it is essential to keep us in our trusted role. There is increasing activism promoting that our Professional Societies should be more vocal in addressing societal issues (17), such as the SCOTUS ruling. When society takes a wrong turn, and medical professionals go along, mistrust in medicine grows. As John Lewis once said, we should not be afraid to get into a “little bit of good trouble, necessary trouble” (18). We must do all this with deep respect for the diversity of views within our membership, and a recognition that our organizational leadership does not fully represent the views of all the members of our College, although greater representativeness is another ACR goal going forward. We must continue to represent our members well and thread the needle between big picture visionary work, that may include activism, and staying in a more narrowly focused rheumatology lane. We have to build trust among our many affiliated colleagues. We should be open to those who want to engage in difficult discussions, often with views that may be different or unpopular. Civility and an attempt to understand those with whom we see things differently is critical for the ACR and for the world overall. Our Board of Directors and our members at large had some great new ideas this year: tiger teams, micro volunteer groups of mostly private practice providers, and creation of safe spaces to mull controversies. These approaches will allow us to more rapidly, more effectively, and more parsimoniously address geopolitical issues that come our way, and we should maintain a presumption of goodness as we strive for the truth. I have been most fortunate during my career to work with so many people who do the right thing and presume goodness in others. My career has been greatly enriched by a wonderful University of Alabama at Birmingham (UAB) Division of Rheumatology with deep talent in research, education, and clinical care. I have been blessed to have had outstanding mentors from medical school, through residency, fellowship, and on to my current position at UAB. I have also been very fortunate to have participated in the career development of many exceptional rheumatologists and rheumatology health professionals. Most of us could not or would not do all the work we do if it were not for the considerable support of a dedicated and loving family: my daughters and granddaughter, my son-in-laws, my parents, and of course, my lovely and wonderful wife Leah, who has put up with my several jobs this year. I love you all. Let me leave you with a few final thoughts on what you can do and what the ACR should do to strengthen trust. First and foremost, we must continue to practice evidence-based medicine. Talk to your patients about important matters—they trust you! Express your true opinions. If I can get my reticent patients in Alabama to take badly needed COVID vaccines, trust does matter and our trusted expertise influences our patients’ actions. We must also talk to our local and national leaders. This past spring at our “Hill Day” in Washington, DC we heard eloquent and largely bipartisan remarks from physician members of Congress who represented opposite parties. It would help our country if more rheumatologists entered politics, but, at a minimum, we need to participate in policy-making at the highest levels. Get involved. We need more practice members and more diverse members in our ACR leadership. Volunteer yourself, or encourage your colleagues to participate in committee work. Achieving greater equity will build trust. Finally, while we must stay in our lane and focus on clinical and academic rheumatology, our lane and the lanes of other medical organizations are widening. The ACR cannot and should not shy away from controversy; we should be doing this while representing our members fairly. I am an optimist, even in these polarized times, and I believe this most eloquent statement of Dr. Martin Luther King, Jr.: “The arc of the moral universe is long but it bends towards justice” (19). I thank you for trusting me in this ACR role, and for each of you being such trusting servants of our patients and the community of rheumatology, now and going forward. Disclosure Form Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.